Cancer patients turning up in emergency departments with delirium likely to die earlier

August 01, 2017

According to a new study published in The Oncologist, patients with advanced cancer who are diagnosed with delirium when turning up in emergency departments are more likely to be admitted to hospital and more likely to die earlier than patients without delirium. This shows the importance of accurately diagnosing delirium in advanced cancer patients, says lead author Ahmed Elsayem at the University of Texas MD Anderson Cancer Center in Houston, TX, even though delirium can easily be missed in busy emergency departments.

In patients with advanced cancer, delirium can be caused by various different factors. "Advanced cancer itself is a major cause, and other problems such as medications or infection are triggers that can precipitate the full blown syndrome," explains Elsayem. Previous studies have shown that delirium is associated with poor survival in advanced cancer patients being treated in intensive care units (ICUs) or receiving palliative care in hospices, but no one had investigated whether the same was true for those reporting to emergency departments.

"To the best our knowledge this is the first study to show the poor survival of advanced cancer patients in the emergency department setting," says Elsayem.

This study follows on from an earlier study conducted by Elsayem and his colleagues in which they assessed the frequency of delirium in advanced cancer patients visiting the emergency department at MD Anderson. They tested for delirium using two separate questionnaires, classifying patients as suffering from delirium if at least one of the questionnaires gave a positive result.

Questioning 243 patients in total, they found that 44, or 18%, were suffering with delirium according to at least one of the questionnaires. In this current study, they investigated the proportion of these cancer patients with and without delirium that were subsequently admitted to hospital and ICUs, and recorded how long they lived after their visit to the emergency department. They also looked at whether possessing advanced directives, which specify the treatments a patient wants to receive if they are no longer able to make decisions for themselves, influenced the rates of hospitalization and survival.

They discovered that the majority of cancer patients with delirium were admitted to hospital (80%), whereas only 49% of those without delirium were admitted; patients with delirium were also much more likely to be admitted into the ICU. Advanced cancer patients with delirium were also likely to die earlier, surviving for a median time of between one and four months after their visit to the emergency department, compared with a median survival time of over 10 months for patients without delirium. Although around half of the patients had advanced directives, these did not seem to have any effect on the rates of hospitalization or survival.

Given the major influence delirium appears to have on survival, as well as the distress it can cause for patients and their family members, Elsayem says that prompt diagnosis and management in hospital emergency departments is essential. Especially as, in many cases, delirium in advanced cancer patients can be resolved by simply stopping or modifying their medication and treating any associated infections. "Treating the triggers if known - such as stopping medications - is the main treatment for an episode of delirium," says Elsayem.

He also suggests that further research needs to be done on this topic, including conducting similar studies on delirium in advanced cancer patients in other emergency departments and with larger groups of patients.

"This prospective cross-sectional study of patients with advanced cancer provides new information about the identification of delirium in the emergency department," said Russell Portenoy, executive director of the MJHS Institute for Innovation in Palliative Care, NY, who is a section editor of The Oncologist and was not involved in the study. "The key findings - that delirium is a poor prognostic sign and that many patients who present with delirium lack advance directives - underscore the need for competent assessment to identify delirium and follow this diagnosis with a plan of care informed by the increased risk of mortality. Importantly, presentation with delirium in the emergency department should trigger evaluation of advance directives, which, if lacking, can be obtained or refined if capacity is present or restored by treatment of the delirium.
-end-
Additional Information

Full citation: "Advance Directives, Hospitalization, and Survival among Advanced Cancer Patients with Delirium Presenting to The Emergency Department: a Prospective Study." Ahmed F. Elsayem, Eduardo Bruera, Alan Valentine, Carla L. Warneke, Geri L. Wood, Sai-Ching J. Yeung, Valda D. Page, Julio Silvestre, Patricia A. Brock, Knox H. Todd. The Oncologist. Published Online: August 1, 2017; DOI: 10.1634/theoncologist.2017-0115.

URL Upon Publication: http://dx.doi.org/10.1634/theoncologist.2017-0115

Author Contact: To arrange an interview with the author, please contact Julie Penne at MD Anderson Public Relations (jpenne@mdanderson.org; +1 713-792-0662).

About The Oncologist

Now celebrating its 22nd edition, this internationally peer-reviewed journal focuses on clear and concise interpretation addressing the multimodality diagnosis, treatment and quality of life of the cancer patient. Each issue is meant to impact the practice of oncology and to facilitate significant communication in the introduction of new medical treatments and technologies. The Oncologist is the official journal of the Society for Translational Oncology (STO).

About AlphaMed Press Established in 1983, AlphaMed Press, which has offices in Durham, NC, San Francisco, CA, and Belfast, Northern Ireland, is the publisher of three internationally renowned peer-reviewed journals. The Oncologist®, which is entering its 20th year, is devoted to community and hospital-based oncologists and physicians entrusted with cancer patient care. STEM CELLS®, celebrating its 35th year, is the world's first journal devoted to this fast paced field of research. STEM CELLS Translational Medicine®, currently in its sixth year, is dedicated to significantly advancing the clinical utilization of stem cell molecular and cellular biology.

About Wiley

Wiley, a global company, helps people and organizations develop the skills and knowledge they need to succeed. Our online scientific, technical, medical and scholarly journals, combined with our digital learning, assessment and certification solutions, help universities, learned societies, businesses, governments and individuals increase the academic and professional impact of their work. For more than 200 years, we have delivered consistent performance to our stakeholders. The company's website can be accessed at http://www.wiley.com.

Wiley

Related Palliative Care Articles from Brightsurf:

Palliative care needed across China for everyone who needs it -- study
Palliative care should extend across China and pay more attention to managing non-malignant disease -- integrated within the country's healthcare system and available to everyone who needs it, according to a new study.

New palliative care model shown to reduce costs without compromising on quality of care
Findings from a large-scale clinical trial testing a new palliative care model have shown to be lower cost, viewed positively by patients and their carers while showing no difference in patient-reported outcomes when compared with standard care.

Palliative Care in emergency departments during COVID-19 pandemic
The clinical characteristics and outcomes of patients who received intervention by a COVID-19 palliative care response team are examined in this case series.

Palliative care for patients with cancer in COVID-19 era
The considerations and challenges affecting the palliative care specialty and delivery of palliative care in the COVID-19 era, as well as potential solutions, are discussed in this Viewpoint.

To face coronavirus disease 2019, surgeons must embrace palliative care
This Viewpoint describes the relevance of a palliative care approach to surgery during the coronavirus disease 2019 pandemic.

Call for palliative care to be adapted for severely ill Covid-19 patients
Emergency-style palliative care needs to implemented to meet the needs of Covid-19 patients who wouldn't benefit from a ventilator say researchers.

A COVID-19 palliative care pandemic plan: An essential tool
Palliative care physicians have created a coronavirus disease 2019 (COVID-19) palliative care plan as an essential tool to provide care and help manage scare resources during the pandemic.

MAiD is not driven by socioeconomic vulnerability or poor access to palliative care
A new study of people who received medical assistance in dying (MAiD) in Ontario found that about three-quarters were cared for by palliative care practitioners at the time of their request for MAiD, and MAiD recipients were younger, wealthier and more likely to be married than the general population at time of death.

Palliative vs. standard care for Parkinson's disease
This randomized clinical trial that included 210 patients with Parkinson's disease and related disorders and 175 caregivers examined whether outpatient palliative care was associated with better patient or caregiver outcomes compared with standard care.

Palliative care in hospitals linked to decrease in use of ICU; treatment intensity
A new study shows that implementing hospital-based palliative care services in New York State reduces treatment intensity at the end of life for hospitalized patients.

Read More: Palliative Care News and Palliative Care Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.